Provider Demographics
NPI:1548037278
Name:INDIANA DENTAL ASSOCIATES
Entity type:Organization
Organization Name:INDIANA DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-530-7550
Mailing Address - Street 1:1600 E 93RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3607
Mailing Address - Country:US
Mailing Address - Phone:773-530-7550
Mailing Address - Fax:773-530-0287
Practice Address - Street 1:1901 GRANT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-2761
Practice Address - Country:US
Practice Address - Phone:219-880-1430
Practice Address - Fax:219-239-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty